Zagazig university Faculty

of nursing
Doctorate degree (First term)

Intrapartum fetal surveillance

Under supervision of
Dr

Sabah Lotfy Mohamed

Prepared by

Noha Elsayed Mahmoud Radwan

2016

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  Definition of Intrapartum fetal surveillance

Fetal surveillance includes both electronic methods of monitoring fetal

wellbeing (e.g. cardiotocograph) and non-electronic methods (e.g. fetal blood
sampling). FHR monitoring can occur via intermittent auscultation or continuous
cardiotocograph (CTG).
 Aim of intra partum fetal surveillance:-
1- Prevent adverse perinatal outcomes arising from fetal metabolic acidosis
related to labour.
2- Determine whether or not a fetus is well oxygenated; as the fetal brain
modulates the fetal heart rate through an interplay of sympathetic and
parasympathetic forces.
 Methods of assessment of fetal heart rate during labor:-
1. Recording FHR intermittently by fetoscope or sonicad or by
continues electronic fatal monitoring.
2. Sampling of blood from fetal scalp for PH.
3. Observation for the presence of me conium in the amniotic fluid.

(I)- Fetal heart rate

The fetal heart rate may be assessed intermittently or continuously.
(A)-Intermittent recording (IA) is used when FHR is ausucltated in
Intervals using a Pinard stethoscope or sonicad.

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The rate : IA during active labor should be performed towards the end and after a
contraction for at least 60 seconds( normal range (110-160)).
Tachycardia: Acceleration of FHR above 160bpm(mild hypoxia causes
sympathetic stimulation).
Bradycardia: Slowing of FHR below 110 bpm (moderate hypoxia causes vagal
stimulation)
Cardiac arrhythmias: irregularities(marked hypoxia)

Interval for auscultation FHR

Low risk women
• First stage: Latent phase …..every 60 minutes.
Active phase……every30minutes.
• Second stage every15 minutes

High risk women

• First stage: Latent phase …..every 30 minutes.
Active phase……every15minutes.
• Second stage: every 5 minutes

(B)- Continuous recording by electronic monitor(CTG)

FHR can be recorded by:
External method via an ultrasound transducer applied to the mothers
abdomen. It detects the closure of cardiac valve.
Internal method via a special electrode attached to the fetal scalp.
Uterine contraction can be recorded by:
External method via a tocometer applied in the mothers abdomen. It
recodes the movements of the anterior abdominal wall occurring with the
uterine contractions.

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 Internal method via a special electrode introduced into the uterine cavity. It
measures intrauterine pressure.
Internal methods cannot be used unless the cervix is partly dilated(more than 2cm)
and rupture of membrane.

In situations where it is not possible to get a good quality FHR pattern with an
external electrode, an internal electrode may be considered. Contraindications to
the use of an internal electrode include: Maternal infection (for example, HIV,
hepatitis viruses and herpes simplex virus), Fetal bleeding disorders (for example,
haemophilia) and Prematurity (<34+0 weeks).
Complication of the use of an internal electrode include infection of the fetal
scalp or amnion and trauma to the fetus, placenta or uterus.

At the commencement of continuous EFM the following information should be

documented on the CTG trace:
• The woman’s name
• The woman’s medical record number
• Estimated gestation
• Maternal pulse rate
• Clinical indications for performing the EFM
• Time and date of commencement.

Risk Factors requiring Intrapartum continuous EFM

There are a number of antenatal and intrapartum risk factors that guide the use of
intrapartum continuous EFM. These risk factors are listed below:-
a) Ante natal Risk factors requiring Intrapartum EFM:- Risk Factors
 >42+0 weeks

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  Amniotic fluid index (AFI) <5cm or >25cm
 Abnormal Doppler waveform studies
 A sudden elevation of BP >25+0 weeks gestation
 Uncontrolled or progressing pre-eclampsia or hypertension.
 Antepartum haemorrhage (APH)
 Unstable gestational or insulin dependent diabetes.
 Preterm rupture of the membranes <37+0 weeks.
 Preterm uterine activity.
 Intrauterine growth restriction (IUGR)
 Decreased fetal movements.
 Any other obstetric conditions that increases the risk of fetal compromise.

b) Intra partum Risk factors requiring Intrapartum EFM Risk Factors

Requiring In
 Induction or augmentation with Oxytocin.
 Significant meconium stained liquor.
 EFM may be considered when light meconium
 staining is present following a full clinical assessment
 Any non-reassuring FHR feature heard on auscultation
 Breech presentation
 Multiple pregnancy
 Prolonged labour >12 hours
 Prolonged second stage >2 hours
 Vaginal birth after any previous caesarean section (VBAC).
 Prolonged rupture of membranes >24 hours
 Regional analgesia
 Fresh vaginal bleeding that develops in labour.

Advantages and disadvantages of continuous CTG monitoring

Continuous CTG monitoring

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Disadvantages  Limits mobility of the woman and restricts the use of massage,
different positions and/or immersion in water to improve
comfort and coping strategies
 May shift staff focus and resources away from the mother
 Associated with increased risk of caesarean birth and operative
vaginal birth

Advantages  Provides measurable parameters related to FHR patterns

 Provides a continuous recording of FHR and uterine activity
that may be useful for counselling parents if there has been an
adverse outcome, for clinical audit or medico-legal situations
 Is associated with a reduction in neonatal seizures

Reversible causes for an abnormal CTG and possible actions

Possible cause of Possible contributing
abnormal CTG factors
Cord compression or
reduced placental •Maternal position
perfusion • Maternal hypotension
• Recent maternal:
o vaginal examination
o bedpan use
o vomiting or vasovagal
episode
o siting of epidural or top
up
o rupture of membranes
Possible corrective actions
 Advise maternal
position change (encourage
adoption of left lateral
position).
 Check BP – if
hypotensive, give 500 mL
of crystalloid (maximum
1000 mL).
 Consider vaginal
examination to exclude cord
prolapse or presentation.

Uterine
hypercontractility  Oxytocin infusion • Stop oxytocin infusion2,4
 Recent vaginal while reassessing labour and
prostaglandins fetal state
• Remove prostaglandins

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Maternal tachycardia/  Maternal infection
pyrexia  Tocolytic infusion
 Dehydration
 Anxiety/pain may
cause tachycardia without
pyrexia
Inadequate quality of  Poor contact from
CTG external transducer.
 Fetal scalp electrode
(FSE) not working or
detached
Findings: CTG provide information on:
 Baseline FHR.
 Baseline variability.
 Response of the fetal heart to uterine contraction.
Abnormal FHR patterns:
(a)- Abnormal baseline FHR changes:
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(PGE2/cervidil)
• Consider tocolysis options.
o Terbutaline 250
micrograms subcutaneously
or IV.
o *Sublingual Glyceryl
Trinitrate (GTN) spray 400
micrograms.
o Salbutamol 100
micrograms IV.
 If temperature greater
than 38o C consider
screening and treatment.
 If pulse greater than
140 bpm reduce tocolytic
infusion.
 Check BP, give 500
mL crystalloid if
dehydrated
 Check maternal pulse.
 Reposition
transducer/FSE.
 Consider applying
FSE.
Baseline tachycardia above below 160 bpm due to fetal distress, fetal or maternal
anemia.
Baseline bradycardia below 110 bpm due to fetal distress, B-blockers given to the
mother.
(b)- Baseline variability:
 Loss of baseline variability due to fetal distress, fetal sleep, sedatives.
 Sinusoidal FHR Pattern: a regular oscillation of the baseline long-term
variability resembling a sine wave. This smooth, undulating pattern, lasting
at least 10 minutes, has a relatively fixed period of 3–5 cycles per minute
and an amplitude of 5-15bpm above and below the baseline. Baseline
variability is absent. rarely
(b)- Response of FHR to uterine contraction:
 Early Decelerations: Uniform, repetitive, periodic slowing of the FHR with
onset early in the contraction and return to baseline at the end of the
contraction.
 Late Decelerations: Uniform, repetitive, periodic slowing of the FHR with
onset at the mid to end of the contraction and deepest point more than 20
seconds after the peak of the contraction and ending after the contraction. In
the presence of a non accelerative trace with baseline variability less than
5bpm the definition would include decelerations less than 15bpm.
 Variable Decelerations: Variable, intermittent periodic slowing of FHR
with rapid onset and recovery. Time relationships of the deceleration with
the contraction cycle are variable and they may occur in isolation.
Sometimes they resemble other types of deceleration patterns in timing and
shape. Variable decelerations can be Typical or Atypical variables.

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Prolonged Decelerations: A sudden fall in the FHR for longer than 3 minutes but
less than 10 minutes.

(2) Intrapartum fetal blood sampling

Definitions
FBS: Fetal blood sampling
Lactate: is a measurement of the circulating lactic acid.
Lactate Pro: is the device used at the Women’s.
Lactate measurement: is the preferred method of FBS at the Women’s. Lactate
sampling is more likely to be successful and the result available more quickly than
pH sampling. It requires a smaller volume, so has a higher sampling success rate
and is a point of care test. The use of scalp lactate rather than pH measurement
provides an easier and more affordable adjunct to EFM for most units .
Petroleum jelly is also known as soft white paraffin gel.
Characteristic Comment
Contraindications
• Clear evidence of severe fetal compromise
• Maternal infection (for example, HIV, hepatitis viruses
and herpes simplex virus)
• Fetal bleeding disorders (for example, haemophilia)
• Prematurity (less than 34 weeks)
• Malpresentation, including breech
• Relative contraindications (discuss with Consultant
Obstetrician)
• Gestation range 34 weeks to 36 weeks and 6 days
• Maternal pyrexia above 380C
Sample collection • Woman positioned:
o left lateral position or
o lithotomy with a wedge in place
• Check blood pressure and give 500 ml crystalloid (IV) if
appropriate.

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Interpretation • Fetal blood sampling should be interpreted taking into
account:
o any previous measurement
o the rate of progress in labour and
o other clinical circumstances
• Umbilical cord arterial and venous blood should be collected at
the time of birth to confirm acid base status when:
o fetal blood sampling has been performed intrapartum and/or
o fetal compromise has been identified by FHR monitoring

Procedure:-
 Ensure that the Lactate ProTM machine is available, calibrated and
functioning.

 The membranes must be ruptured and the cervix at least 3 cm dilated for the
procedure to be attempted.

 Other technical considerations include the amount of effacement, station,

application of the vertex to the cervix, volume of amniotic fluid and amount
of baby hair

 This procedure may be uncomfortable and intrusive for the woman. It is

invasive to the fetus.

 Explain the procedure to the woman and obtain verbal consent.

 Assemble the equipment on the trolley

 Place the woman in the left-lateral position or in lithotomy with a wedge

under the right hip to reduce the risk of supine hypotension.

 Sampling is performed under direct vision via an amnioscope to avoid

contamination with amniotic fluid.

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  The incision site is carefully cleaned and a thin layer of petroleum jelly is
applied.

 The baby’s fontanelles should be avoided.

 Disposable blades, fixed in a plastic mount are used in a blade holder from
which the blade does not protrude more than 2mm.

 A 2mm fetal scalp incision is made with steady pressure of the blade.

 The blood is collected in pre-heparinised glass capillary tubes.

 Pressure is applied to the incision site with a dry swab until the bleeding
stops.

 Discard the blade in the sharps container.

 Document the procedure, the result and the subsequent plan of management.

 Postnatal examination of the baby should include examination of the

sampling site.

Intrapartum fetal blood sampling results

Interpretation pH Lactate (mmol/L)
Normal Greater than or equal Less than 4.2
to 7.25
Repeat in 30 mins 7.21 - 7.24 4.2 - 4.8
Birth expedited Less than or equal to Greater than 4.8
7.20
Urgent birth indicated Less than 7.15 Greater than 5.0

Complications
Complications of FBS are very rare and include haemorrhage, infection and
breakage of the blade.

(3)-Observation for the presence of meconium in the amniotic fluid:-

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Following ROM, amniotic fluid escapes from the uterus continuously and may
provide information about the condition of the fetus. This fluid should normally
remain clear.
If the fetus becomes hypoxic ─ pass meconium, as hypoxia cause relaxation of the
anal sphincter. The amniotic fluid becomes green as a result of meconium
staining.
Amniotic fluid which is a muddy yellow color or which is only slightly green may
signify previous distress from which the fetus has recovered.
If the breech is presenting and is compacted in the pelvis, the fetus may pass
meconium due to the compression of the abdomen ,a fetus presenting by the breech
is also prone to fetal distress and may pass meconium as a result of hypoxia.
In rare case of a fetus that is severely affected by rhesus iso-immunization the
amniotic fluid may be golden-yellow due to an excess of bilirubin.

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